Diabetes is Primary 2014 Part 4 - A Diabetes Core Update Special Edition: Diabetes on a Budget; Motivational Skills

Summary

Diabetes Core Update: Diabetes is Primary 2014 Part 4

Special Edition: Diabetes on a Budget; Motivational Skills

Podcast Date: September 3, 2014
Hosts: Dr. Neal Skolnick & Dr. John J. Russell
Guests: Dr. Charles Schaefer & Martha Funnell

Overview

This special episode of Diabetes Core Update features key highlights from the “Diabetes is Primary” conference. The episode focuses on two core topics: managing diabetes on a budget, presented by Dr. Charles Schaefer, and enhancing motivational skills in diabetes care, led by Martha Funnell. Through practical insights and clinical expertise, the speakers address challenges in cost-effective diabetes management and ways clinicians can inspire and empower patients for better health outcomes.

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Main Discussion Points & Insights

1. Managing Diabetes on a Budget

Speaker: Dr. Charles Schaefer, University Medical Group, Augusta, GA
Timestamps: [00:49] – [10:46]

The Challenge of Diabetes and Costs

• Diabetes is expensive — medications and supplies are often costly for patients, especially those with limited insurance.
• However, initial management and prevention can be approached with minimal extra expense.

Zero-Cost and Low-Cost Interventions

• Lifestyle changes:
  • “It doesn’t cost a penny to go around the block for 30 minutes in your neighborhood every day.” ([02:17], Schaefer)
  • Diet modifications, such as reducing fatty and fried foods or simple carbohydrates, can be accomplished affordably.
  • “Weight management costs absolutely nothing.” ([02:54], Schaefer)
• Healthy eating:
  • While healthy, balanced diets can sometimes be more expensive, judicious food choices and elimination of junk food can keep costs reasonable.

Self-Monitoring of Blood Glucose (SMBG)

• SMBG is valuable but can become a significant cost.
• Monitor only when results will impact management:
  • “We ought to only be testing to attain that information, which will lead us to make some change in management.” ([04:21], Schaefer)
  • For type 2 diabetics on oral therapy, frequent readings may not change care.
• Choosing meters and strips wisely:
  • Less expensive alternatives can still be effective.

Medication Choices

• Metformin:
  • “The medication metformin can be gotten almost anywhere for no more than three or four dollars a month.” ([06:40], Schaefer)
• Sulfonylureas:
  • Although concerns exist regarding side effects, especially hypoglycemia, low-dose regimens are still budget-friendly and widely used.
  • “It’s entirely possible to get good diabetic control with metformin and low dose sulfonylurea combined.” ([08:05], Schaefer)
• Insulins:
  • Basal analog insulins are expensive, but NPH insulin is much less costly and evidence supports its efficacy.
  • “The much more expensive insulin products are no better than a very inexpensive product called NPH insulin at reducing the A1C.” ([09:08], Schaefer)
• Summary:
  • Effective diabetes management can often be achieved using affordable therapies, provided patient safety is monitored.

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2. Motivational Skills in Diabetes Management

Speaker: Martha Funnell, Michigan Diabetes Research and Training Center
Timestamps: [10:50] – [20:27]

The Nature of Motivation

• Motivation is internal:
  • “Our ability to provide motivation has to rely on the patient’s internal motivation… It really becomes our job not to motivate people, but to give them messages in a way that they can use for that internal motivation. So I always think of it as our job is to be inspirational, but not motivational.” ([11:37], Funnell)
• Understanding patient perspectives:
  • Patients are always motivated, “just not motivated to do what we think they should.” ([12:45], Funnell)
  • Start by identifying what is important to the patient: their worries, concerns, and fears.

Individualizing Communication & Care

• Active listening:
  • “The most important communication skill… comes down to listening. It comes down to finding out what’s important for you… what are the other barriers and stresses in your life.” ([14:15], Funnell)
  • Recognize that diabetes may not be every patient’s top priority.
• Address diabetes-related distress:
  • Acknowledge the emotional burden and its impact on self-management.

Clinician-Patient Partnership and Empowerment

• Defining roles:
  • “There are very few jobs in the world where you wouldn't get that kind of orientation. And yet self-managing a very complex chronic disease is not one where we typically have a discussion about here's what I can do. But the reality is 99% of this is in your hands. And I need to know how to best help you to be the most effective self manager.” ([16:09], Funnell)
• Start each visit with patient’s goals:
  • While it may feel risky to let patients set the agenda, this can actually make visits more productive and efficient.
  • “Begin every visit with asking the patients what they need to accomplish during that visit. And while that’s very scary for health professionals… we know from a variety of studies that can actually shorten the visit because you accomplish what the patient needs to get addressed in the first minute or two.” ([16:55], Funnell)

Overcoming Barriers in Practice

• Time constraints:
  • Use available time to break repetitive patterns and experiment with new approaches to patient engagement.
• Team-based care:
  • Rely on the broader healthcare team—care managers, educators, etc.—to support patients.
  • “Nobody can do this alone. It truly takes a team… That’s what patients in our medical homes are all about.” ([19:27], Funnell)
• Clinician adaptability:
  • “In reality, we need to do things differently if we want to see the kind of changes in the outcomes that we want.” ([20:03], Funnell)

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Notable Quotes & Memorable Moments

• On affordable lifestyle interventions:
  • “It doesn’t cost a penny to go around the block for 30 minutes in your neighborhood every day.”
    — Dr. Charles Schaefer ([02:17])
• On the cost-effectiveness of medications:
  • “The much more expensive insulin products are no better than a very inexpensive product called NPH insulin at reducing the A1C.”
    — Dr. Charles Schaefer ([09:08])
• Motivation as internal, not external:
  • “Our job is to be inspirational, but not motivational.”
    — Martha Funnell ([11:59])
• Everyone is motivated—just perhaps not in the clinician’s direction:
  • “Everybody’s motivated. They’re just not motivated to do what we think they should.”
    — Martha Funnell ([12:45])
• On giving patients ownership:
  • “Begin every visit with asking the patients what they need to accomplish during that visit… that can actually shorten the visit.”
    — Martha Funnell ([16:55])
• A team approach is essential:
  • “Nobody can do this alone. It truly takes a team.”
    — Martha Funnell ([19:27])

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Key Takeaways for Clinicians

• Effective diabetes management for patients on a budget is feasible using lifestyle modifications, targeted monitoring, and selection of cost-effective medications.
• Motivational interviewing skills are crucial—focus on listening, individualizing care, and partnering with patients.
• Empower patients by acknowledging their role in self-management, and use the healthcare team for support.
• Adjust clinical approaches to maximize both efficiency and impact, especially under time constraints.

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Transcript

[A]

Hello, I'm Dr. Neal Skolnick and I'd like to welcome you to a special edition of Diabetes Core Update. On this podcast, we will be interviewing faculty who are presenting during the American Diabetes Association Scientific Sessions Diabetes is primary conference on June 14, 2014. Today we will be hearing highlights of a Talk given by Dr. Charles Schaefer on managing diabetes on a budget, as well as an excellent talk by Martha Funnell discussing motivational skills in the management of diabetes.

[B]

We're now going to talk again with Charles Schaefer, who is a senior partner of the University Medical group in Augusta, Georgia. Dr. Schaefer is someone we heard from earlier in a previous podcast about his plenary session on screening for diabetes. He also did a superb workshop on can diabetes be taken care of on a budget? Something that's important to all of us, taking care of patients who have a limited budget, which is just about everybody, and particularly for patients who might not have the best insurance. Charlie, welcome. And the large question, can diabetes be.

[C]

Taken care of on a budget?

[D]

Well, Neil, thank you very much for asking me to join you today. I will have to tell you that the word budget and diabetes hardly fit in the same sentence. It would seem these days. Diabetes is a very, very expensive disease. The range of antidiabetic therapies that we have today are really very, very expensive, with only a few exceptions. So it's a valid question to ask, but the answer is it can. A lot of what we do to initially manage diabetes, and perhaps even more exciting is some of the things that we can do to maybe prevent the likelihood of patients even becoming diabetic are absolutely free. It doesn't cost a penny to go around the block for 30 minutes in your neighborhood every day. It doesn't cost anything to alter your diet. Reducing fatty and fried foods and trying to reduce the simple carbohydrates and simple sugars that are so bad about increasing blood sugar levels to alter a diet like that really can be done without any great expense at all. And then finally, weight management costs absolutely nothing. Now, I don't want to be flippant, because eating the proper, healthy, well balanced diet that is necessary for optimal diabetes management can increase cost of care a bit. But if one selects carefully and gets rid of some of the junk food and other things that add to the cost of food cost. Yeah, it's possible to prevent and initially treat diabetes without a tremendous amount of added expenditure.

[B]

That's a great point. How about things like self monitoring? Does that influence the cost of treating diabetes?

[D]

Well, this is an interesting area, Neil, because we have a need for self monitoring. It certainly provides information. And as we know, knowledge is power and often our patients really need to see, what did that meal do to my blood sugar? What did that snack do to my sugar? And that can often factor into making wise choices down the line. So self monitoring is both a good thing, but it's also a bad thing, and at times can become one of the most expensive aspects of diabetes management. So I think one point in regard to self management that we need to focus on is the fact that we ought to only be testing to attain that information, which will lead us to make some change in management. For many of our type 2 patients who are on oral therapy, the self management determinations, while of great interest, really aren't factoring into the day in and day out diabetes care. So, first of all, we need to really ask the question, is my testing altering in any way my therapy? Then the other thing we need to keep in mind is that there are a variety of meters and strips available that, like so many things in life, may be a little more expensive to get some convenience or some benefit, but they're less expensive strips that also will reasonably accurately check the blood sugar and allow someone to intermittently know where that blood sugar is without spending a fortune. So I think the answer here is that self monitoring, when used judiciously and wisely, and when one selects reasonably priced equipment to do that, certainly can be accomplished without breaking the diabetes care budget.

[B]

That's great. It really is important that we target our degree of monitoring to what we're going to do with the results. Charlie, how about medications? How should we approach medicines with regard to attention to budget?

[D]

Yeah, now we're getting into the more complicated area of diabetes management on a budget, but it's not an impossible area, Neil. We've got lots of antidiabetic therapies, probably, depending on how you parse this out, about a dozen different classes of drugs that range from very, very inexpensive to very expensive. And I think that where budgetary constraints are our biggest concern, we still have plenty of things to choose from that can get the job done. Our mainstay, the foundational medication that we use. Of course, we use all medications on top of the free lifestyle changes, but the medication metformin can be gotten almost anywhere for no more than three or four dollars a month. So the cost of that medication is really quite reasonable. Next, we might add two Metformin. If control is not adequate on that drug. And we have a variety of medications from, again, very Inexpensive to very expensive. And while there's been a lot of discussion in the literature and among diabetes exper about the long term impact of taking sulfonylureas, a very inexpensive class of oral antidiabetic therapy, many diabetic experts will testify that in fact low dose sulfonylurea when carefully used by practitioners and specifically when patients have been advised about.

[C]

The.

[D]

Signs and symptoms of hypoglycemia, which is a side effect of these drugs, if everybody involved in the use of the drug is really paying attention, it's entirely possible to get good diabetic control with metformin and low dose sulfonylurea combined. Now after that there really aren't any low dose oral choices. The cost goes up dramatically. And neo for my patient population, many of whom are Medicare recipients and worried about falling into the doughnut hole, these very expensive medications become very problematic. But we know from a number of trials dating back from the beginning of analog basal insulins that in fact the much more expensive insulin products are no better than a very inexpensive product called NPH insulin at reducing the A1C. As a matter of fact, A1C reduction is identical that was shown in a number of studies at the advent of analog basal insulins. So one can go from metformin to low dose sulfonylurea to careful application of NPH insulin and ought to be able to achieve reasonably good control. Excuse me, reasonably good control in a significant number of patients. Neil, as you know, there are some international experts, particularly from Western Europe, who are very fond of saying that they will show you their data with metformin and sulfonylurea and NPH insulin and they'll show you that they're getting exactly the same beneficial results that we get with a lot of our more expensive products. Again, we need to keep in mind that the more expensive products tend to come with greater convenience. They may only have to be taken once a day, they may have lower risk of hypoglycemia or lower risk of weight gain. But the actual diabetic control, which is the thing that we're after at the end of the day, is really not significantly improved by using a more expensive class of medication.

[B]

Those are great points, Charlie. I want to thank you so much for joining us for sharing all that information. What an exciting talk and I think very helpful. Again, thank you, Neil.

[D]

Thank you for the invitation. It's been a pleasure to be with you.

[B]

We're now going to hear from Martha Fennell, who is an associate researcher, research scientist in The Department of Learning Health Sciences at the Michigan Diabetes Research and Training Center. Martha, is giving an excellent talk on motivational skills for patients with diabetes. Marty, welcome to our podcast.

[C]

Thank you very much.

[B]

This is an exciting talk because clearly, motivational skills overlay everything we do as clinicians with our patients with diabetes. And it's something that we don't think about all the time, but we're involved with all the time. Why don't we start out by talking about what is motivation?

[C]

Well, you know, I think motivation is one of those concepts that gets a lot of discussion in diabetes, but nobody quite knows what it means or what to do about it. I think in many ways, true motivation is actually internal motivation, and I think that's important for health professionals to think about that. Our ability to provide motivation has to rely on the patient's internal motivation in their internalizing those messages. So it really becomes our job not to motivate people, but to give them messages and in a way that they can use for that internal motivation. So I always think of it as our job is to be inspirational, but not motivational.

[B]

I love the idea of inspirational and, in a way, tapping into people's internal motivations. Clearly, some people are motivated, some aren't. Why aren't some people with diabetes motivated to take care of themselves and their diabetes?

[C]

Well, everybody's motivated. They're just not motivated to do what we think they should. Our patients are 100% motivated to accomplish their own goals. So I usually begin from the point of view that people want to be healthy. I've never had a patient say, you know, I really hope I get all the complications. And so I start from that point and really try to help the patient identify what's important for them. What are they worried about? What are they concerned about? What's their biggest fear about diabetes? Because often, while fear messages that other people give you are not particularly motivational, in fact, they usually have the opposite effect. It's something that we use internally as a way to help us to make changes and to do the things that we want to and should do. So I think the first thing is really to understand what is motivational for that patient, what is important for that patient. Everybody's. I come at it from the point of view that everybody's doing the very best that they can, and my job is to help them find ways to perhaps do that better.

[B]

And I love that message about the importance of individualizing what we do with patients, because what motivates me may be very different than what motivates you or someone else. What can one as clinicians do to help motivate our patients?

[C]

Well, you know, I don't have a magic wand, which is what I occasion. And it really comes down to treating every recognizing that our patients are individual. And the most important communication skill is not some message that I can give you or five magic words that will help your patients to, to make those decisions. It really comes down to listening. It comes down to finding out what's important for you. What are you worried about? What are the other barriers and stresses in your life? Diabetes for our patients with type 2 diabetes is often one more thing on their list of 800 priorities. And while we think it should be number one, it probably won't be for many of our patients. And so I think it's really helping patients to think about what are the other things going on in their lives and what is it that they need from us that will help them to be successful again, assuming that people want to be healthy, they want to live long lives, they want to have a high quality of life. And I think also to acknowledge the impact of diabetes related distress on motivation and behavior.

[B]

That's fantastic. It's interesting. As I'm listening to you speak, I'm realizing that in so many of lectures, what we hear is information. And I think what I'm hearing here today is wisdom. Yeah. What are some strategies that I can use to motivate and inspire my patients to participate more actively in their career?

[C]

I think first of all is to talk to them and ask them. And also one of the things that we don't do very well in health care is to have a conversation with our patients about what our job is and what their job is. There are very few jobs in the world where you wouldn't get that kind of orientation. And yet self managing a very complex chronic disease is not one where we typically have a discussion about here's what I can do. But the reality is 99% of this is in your hands. And I need to know how to best help you to be the most effective self manager. So you tell me and have that conversation with the patient. I think the answer is to always begin every visit with asking the patients what they need to accomplish during that visit. And while that's very scary for health professionals because we don't like to give up control and we're very worried about the time, we know from a variety of studies that can actually shorten the visit because you accomplish what the patient needs to get addressed in the first minute or two. And Then you can go on and fulfill your agenda as well. But again, it gives the patient the message, this is your disease. All I can do is be your coach. All I can do is give you information and advice. But at the end of the day, your outcomes are largely in your hands.

[B]

That sounds very Zen, like, by giving you the control, I can accomplish more of what I want to accomplish.

[C]

Yeah, actually, we don't give our patients control. They pretty much have it.

[B]

That also sounds like. No, yeah, it is. And you know, it. Also, it strikes me when we look at things like adherence data, how well are you at taking your medicines? Our patients often don't take their medicines as well as we think. And by giving them more opportunity to participate, I'll bet you that they. They are better at then carrying things out and taking their medicines.

[C]

Well, certainly the data that are out there support that. So, yes.

[B]

And then lastly, what are some barriers and how do we overcome those barriers that are caused by the realities of practice today?

[C]

Sure. And I think clearly time constraints are very real. And so I think part of it. I think there are two things. One is to think about, yes, I only have 10 minutes, but how can I use that time effectively instead of continuing to do the same thing that we do at every visit in the back of our heads, knowing the message is not getting through and leaving the room frustrated. So maybe instead of continuing to do the same thing over and over again, we can think about, how could I change this up? How could I work differently with this patient? And I think the other thing is that physicians in particular need to rely on other members of the healthcare team. Nobody can do this alone. It truly takes a team. And one of the positives that we're seeing from some of the changes in our healthcare settings is an increased availability of people like care managers of others within the team. That's what patients in our medical homes are all about. So hopefully, over time, those changes will have some positive impact. But in the meantime, I think the first thing we need to do, as much as we think our patients need to do things differently, in reality, we need to do things differently if we want to see the kind of changes in the outcomes that we want.

[B]

That's fantastic. And again, I'd really encourage our listeners to go to the webcast to hear more of what you have to say, because both information and wisdom. Thank you, Marty.

[C]

Thank you so much.

[A]

This concludes this special edition of Diabetes Core Update, as well as the series from the Diabetes Is Primary meeting conducted during the scientific sessions this past June for the American diabetes association. I'm Dr. Neal Skolnick, and thank you for listening.

[D]

Sa.

[B]

It.